122 Designing a Financially Sustainable Geriatric-Friendly Emergency Department

Abstract

The American College of Emergency Physicians (ACEP) Geriatric Emergency Department (GED) Guidelines recommend the inclusion of geriatric-trained staff and geriatric equipment in the ED to provide optimal care to older patients. However, the Guidelines and the GED Accreditation process led by ACEP do not provide instructions on how to justify these increased costs to emergency departments. We modeled the costs of staff and equipment and propose a budget-neutral system for a GED. Average staff salaries including the cost of fringe benefits (30% rate) were obtained from a Midwestern hospital with an academic ED of 80,000 annual visits. Average payment for services provided was obtained from the hospital's billing department (geriatric consultations) as well as the 2019 Center for Medicare & Medicaid Services therapy reimbursement rates for moderate complexity therapy evaluations in a Midwest state (https://www.stratapt.com/medicare-fee-calculator). We assumed that all patients were insured by Medicare and/or Medicaid and that hospital personnel work 8-hour days with 4.5 weeks of vacation (237.5 working days/year). We used our ED triage numbers for January 2019 to determine the average number of patients per day who answer “yes” to the triage question, “Do you use a walker, cane or other device to help with mobility?” as an estimate of need for a mobility device while in the ED. For staffing estimates, a nurse practitioner billing at an 85% reimbursement rate for unsupervised geriatric consultations would be budget neutral at 7.1 consultations in the ED per workday. A pharmacist stationed in the ED billing medication management codes for outpatient medication reconciliation would be budget neutral for salary costs at 7.7 consultations per workday. Physical and occupational therapists can also be budget neutral; however, payment for these consultations are generally included in diagnosis-related group (DRG) reimbursements for admitted patients, so not all consultations in the ED would be independently billable. For mobility equipment estimates, electronic medical record data from January 2019 demonstrated that 19% of patients endorse using a mobility aid at ED triage, or about 41 patients per day, with an average length of stay in an ED bed of 8.3 hours. Assuming uniform distribution throughout the 24-hour day, 14 patients would require a mobility aid at the bedside at any given hour. The cost of walkers in our market is $145 each (or $2,030 for 14). Given prior studies estimating the added inpatient cost of one fall to be $7,000-$14,000, the investment in 14 walkers at a total cost of $2,030 would be justified by a cost savings of about $5,000 if a single fall were to be prevented. The cost profile further improves for canes, which cost $26 each in our market. The staff and equipment needed to comply with the Geriatric ED Guidelines is justifiable. Staff who can bill for consultations can be budget neutral practicing within the ED. Additional mobility aids are also a justifiable cost prevention item. This analysis does not factor in ED volume, and all consultations must be medically justifiable to be billable.